Developing inclusive primary care for trans, gender-diverse and nonbinary people

Abstract

W orldwide, meeting the health needs of trans, genderdiverse and nonbinary (TGDNB) people is shifting toward primary care. Presentations to health care providers regarding gender transition are also increasing rapidly. Therefore, all primary care providers need familiarity with TGDNB treatment guidelines and inclusive practice, and more primary care clinicians are gaining the experience and confidence to manage gender assessments and transitions.Four articles collected in this issue of CMAJ raise a number of issues that health care providers should be aware of when working with this population. A large survey by Pinto and colleagues 1 considers the acceptability to clients of including options beyond male and female in clinical records systems; Bonifacio and colleagues 2 discuss the management of gender dysphoria in adolescents by primary care practitioners, providing extensive background and guidance on affirmative care; Beswick and colleagues' case report 3 offers succinct advice on improving processes for cervical cancer screening in trans men; and Lam and Abramovich 4 concisely outline key points for achieving inclusive practice for TGDNB people.Terminology is challenging in this fast-moving field; "umbrella" terms vary across time and nations, including transgender, trans, trans*, trans and gender-diverse, trans and gender-nonconforming. I use "TGDNB," as advised by our consumer advisory panel at the Monash Health Gender Clinic in Australia. In the Canadian context, Pinto and colleagues 1 include "2-spirit" for Indigenous TGDNB people in their broader term: lesbian, gay, bisexual, transgender, transsexual, queer, questioning and 2-spirit (LGBTQ2S).A key shift is from a binary notion of gender as only male or female, with some people moving from one to the other, to seeing gender identity as a spectrum or galaxy. Readers can see some of these shifts in language between the survey questions used in Pinto and colleagues' study, conducted from 2013 to 2016, 1 to the terminology used in Bonifacio and colleagues' more recent review of the care of adolescents who identify as TGDNB. 2 The use of "female to male" ("FTM") by Beswick and colleagues, 3 while still used as an identifier by some trans men, has recently fallen from favour, especially with increasing nonbinary gender identifications, such as bigender (alternating between female and male) or neither male nor female. "Female to male" now usually describes 1 binary process of transition among a range of possibilities, rather than describing people.Trans, gender-diverse and nonbinary people often face difficulties in having their gender identity recognized in clinical records systems. Pinto and colleagues' mixed-methods study 1 provides useful guidance. The survey portion included TGDNB people at higher rates than usual in clinical samples: 1.02% had a diagnosis for gender dysphoria, and 1.22% had no diagnosis, but their gender identity differed from clinical records. However, interpreting the interview portion of the study is somewhat difficult, given a skewed...

Transgender identity and mental health in adolescence: a scoping review

“…Recent expert opinion, however, is that researchers and health professionals ought not to conceptualize gender as binary, since such categorization does not match gender minorities’ experience, (102) but rather understand gender as “a spectrum or galaxy” rather than a binary construct where some people transition from male to female or vice versa. (53) Furthermore, it is possible that in some global settings where sex and gender diversity is not culturally or legally accepted, transgender individuals may take a more gender-fluid approach to gender expression, adaptive to the safety of their environment. Therefore, limiting the present review to a more binary concept of gender, may have resulted in studies of gender fluid adolescents being missed, if any exist.…”

“…Synonyms for ‘transgender’ included the term ‘transsexual’ (in use until recently), ‘travesti’ and ‘2-spirit’ (cultural terms used in the Americas), and the shortened ‘trans’, which is frequently used as an umbrella term for transgender people as well as those who identify as non-binary, gender fluid or questioning their gender identity. The wider group of gender diverse individuals has recently been characterized as ‘TGDNB’ – trans, gender-diverse and non-binary (53); however, this term was not included in the search as it has not yet been widely adopted. The terms ‘gender non-conforming’ and ‘gender incongruent’ were included, after consultation with a librarian, to ensure identification of all studies of adolescents with gender dysphoria seeking to transition.…”

Trans people and blood donation

“…Although societal changes as well as political and legal reforms in the US and Canada have contributed to more openness toward trans people, a great deal of discrimination still occurs. Sources of overt and covert discrimination in health and social service settings include a deficit of knowledge of cultural competence principles in caring for trans people, lack of exposure to trans patients, and struggles to update processes and forms that are currently binary or cisnormative (designed for cisgender people, thus knowingly or unknowingly excluding trans people) …”

Incorporating Transition-Affirming Language into Anatomical Pathology Reporting for Gender Affirmation Surgery

“…4 Accurate representation of their gender identity within health records continues to be a challenge for TGDNB peoples as the health care community struggles to use inclusive terminology in medicine. 5 It has been >25 years since the Canadian McInerney v. MacDonald (1992) case established that patients have the right to access information contained in their health records, and in the United States, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule enfranchises those same rights. 6,7 With ongoing health care advances, medical documen-tation has dramatically changed from hand-written notes to online documentation.…”

“…As part of a process referred to as gender transition, transgender people often seek medical care, including hormone therapy or surgery, to instigate changes in their secondary sex characteristics that more closely approximate the gender with which they self-identify. 5 Gender-affirming surgical procedures include, but are not limited to, penectomy, orchiectomy, reduction thyrochondroplasty, total hysterectomy with bilateral salpingo-oophorectomy, and bilateral total reduction mammoplasty, all of which can result in surgical specimens requiring pathology reports.…”